Perspectives of parents on the meaning of happiness in children with long-term illness: A hybrid concept analysis. — TEI-tagged view

Ruth Nimota NukpezahpersName, Mohammad Ali CheraghipersName, Shahzad PashaeypoorpersName, Akram Sadat Sadat HoseinipersName (2020date). “Perspectives of parents on the meaning of happiness in children with long-term illness: A hybrid concept analysis..” Nursing Opentitle·j.

Object of study — happinessterm·dom in children with chronic diseaseterm·key

Research question — what happinessterm·dom means for children with chronic diseaseterm·key in Ghana, as their parents see it

Contribution — a practical definition of happinessterm·dom in chronically ill Ghanaian children, built from literature and parents' accounts

Full text — tagged

Perspectives of parents on the meaning of happinessterm·dom in children with long-term illnessterm·dom: A hybrid concept analysisterm·mth.

Abstract To define the concept of happinessterm·dom among children with chronic diseaseterm·key.

Happinessterm·dom is an old human quest, the existing literature on the definition of happinessterm·dom among children with chronic diseasesterm·key is sparse.

The three‐phase hybrid model was used. In the first (theoretical) phase, a literature review was conducted. In the second (fieldwork) phase, the semi‐structured interview data were analysed through content analysis. Ten participants were purposively sampled. In the third (final analytic) phase, the practical definition of the concept was identified.

The practical definition of happinessterm·dom in a Ghanaian chronically ill child is the “subjective and positive lifelong process of adapting to biological, physiological, psychosocial, economic and environmental changes caused by the disease trajectory, which affects the well‐being of the child and the family.”

This study offers a background for selecting appropriate health indicators and outcome measures in promoting happinessterm·dom in children with chronic diseasesterm·key.

Keywords: children, chronic diseaseterm·key, concept analysis, happinessterm·dom, hybrid approach, parent's perspectives INTRODUCTION Over the past century, the prevalence of long‐term illnessesterm·dom/chronic diseasesterm·key among children and young people has increased relative to infectious diseases. This situation has left the children with such long‐term illnessterm·dom and their families unhappy (Lim, 2019 ; Ray, 2002 ; Thorne & Paterson, 1998 ; Wijlaars, Gilbert, & Hardelid, 2016 ). A long‐term illnessterm·dom is a sickness that lasts more than three months (Hockenberry & Wilson, 2015 ); it affects a person's normal activities, often requires hospitalization and results in extensive medical care needs (Wijlaars et al., 2016 ). Long‐term illnessesterm·dom, such as asthma, obesity, mental health conditions, leukaemia, sickle cell disease and respiratory conditions, have been seen to threaten our normative ideas of happinessterm·dom (e.g. life satisfaction, felicity, health, well‐being and comfort) (McCormick & Cushman, 2019 ). Children with chronic diseasesterm·key are not happy and satisfied with their lives, when compared to their healthy peers (Post, 2005 ). In addition to this, chronic diseasesterm·key in children cause delays in developmental milestones in areas such as physical, language and communication, reasoning, social and emotional growth (Lim, 2019 ). These delays affect the child, the family members and the nation as a whole due to the resulting economic and social burdens and personal feeling of gross unhappiness (Lim, 2019 ). So what are the definition and the attributesterm·mth of happinessterm·dom in children facing a tenacious ailment like chronic diseaseterm·key? Happinessterm·dom has been defined as the degree to which an individual judges the overall quality of their own life (Ozkara, 2015 ; Rinnan et al., 2018 ). Meanwhile, other researchers also believe that happinessterm·dom is a two‐dimensional construct involving both hedonic (positive emotions and general satisfaction with life) proposed by Carruthers & Hood ( 2004 ) and Cantor, Sanderson, Kahneman, Diener, & Schwartz ( 1999 ) and a eudaimonic perspective (a belief that happinessterm·dom is the fulfilment of positive psychological functioning and human development) (Seligman, 2011 ). Seligman (Peterson, Park, & Seligman, 2005 ) also stated that happinessterm·dom is cumulative and it can exist even when we are not comfortable, fit or satisfied with life. The concept of nurses’ happinessterm·dom (NH) has been well described (Meng, Luo, Liu, Hu, & Yu, 2015 ; Ozkara, 2015 ). However, there is no complete understanding of the meaning of happinessterm·dom among children with chronic diseasesterm·key (Ngamaba, Panagioti, & Armitage, 2017 ). Furthermore, each of the previous studies in the area of happinessterm·dom revealed only some aspects of the concept of the happinessterm·dom (Meng et al., 2015 ; Oishi, Graham, Kesebir, & Galinha, 2013 ; Ozkara, 2015 ; Post, 2005 ), and hence, there is no complete understanding about the different aspects of the concept such as what happinessterm·dom means in children with chronic diseasesterm·key. Moreover, the attributesterm·mth of the concept of happinessterm·dom among children with long‐term illnessterm·dom greatly depend on: the immediate sociocultural context, the qualities of the immediate healthcare system and the type of chronic ailment the children and their families are battling with. All of these aforementioned factors influenced the decision to further classify the concept of happinessterm·dom among the children living with chronic health conditions in Ghana. In addition, anecdotal evidence has suggested that exploring the different aspects of the concept of happinessterm·dom in children with chronic conditions and providing a clear definition for happinessterm·dom based on the immediate context are the prerequisites for the effective fulfilment of happinessterm·dom (Thorne & Paterson, 1998 ). Indeed, given the efforts made in various disciplines to clarify the concept of happinessterm·dom (Ray, 2002 ; Thorne & Paterson, 1998 ; Veenhoven, 2008 ), it can be inferred that the necessity and importance of happinessterm·dom as the essence of nursing care are well acknowledged. A study on achieving happinessterm·dom in chronic health diseases by McCormick (McCormick & Cushman, 2019 ) attributed the emotion (happinessterm·dom) of children with a long‐term illnessterm·dom to “positive health assets,” McCormick defined happinessterm·dom as a process of strengthening the abilities of a child with chronic diseaseterm·key to adjust to environmental challenges, gratify needs and attain goals to improve the well‐being of the child and the family (McCormick & Cushman, 2019 ). Nonetheless, the attributeterm·mth and the definition of this concept remain controversial and there are lots of inconsistencies in its definition; hence, it is deemed worthy of attention in nursing practice (Ferrer‐Cascales et al., 2019 ; Ozkara, 2015 ; Rinnan et al., 2018 ), especially in children with chronic diseasesterm·key. Additionally, self‐reporting of happinessterm·dom is problematic for adults and even more so for a young child who is less skilled in placing instant feelings into a longer perspective. The parents of children with chronic diseasesterm·key are better positioned to describe what happinessterm·dom means to their children (Ray, 2002 ), caregivers are the appropriate guide to fall on in defining the meaning of happinessterm·dom in their children (McCormick & Cushman, 2019 ). Thus, this paper explored the definition of happinessterm·dom in children with chronic diseasesterm·key using a hybrid concept analysisterm·mth research method.

Objectives To define the concept of happinessterm·dom in children with chronic diseasesterm·key so as to attain an in‐depth understanding about the concept in the sociocultural context of Ghana.

METHOD Study design In this study, the concept of happinessterm·dom among children with chronic diseaseterm·key was analysed using Schwartz‐Barcott and Kim's hybrid model. This model of concept analysis consists of three phases: theoretical phase, fieldwork phase and final analysis phase (Schwartz‐Barcott & Suzie Kim, 2000 ). We chose the hybrid concept analysisterm·mth method because its qualitative inclusion of parents’ perspectivesterm·key about what happinessterm·dom means to their children enriched the inadequate research literature in this field.

The theoretical analysis of the concept of happinessterm·dom Theoretical analysis is the first phase in an hybrid concept analysisterm·mth (Schwartz‐Barcott & Suzie Kim, 2000 ). The aim of this phase is to deepen the understanding of the concept of happinessterm·dom in children with chronic diseasesterm·key based on the existing works of research. The four steps in theoretical analysis described by Schwartz‐Barcott and Kim (Schwartz‐Barcott & Suzie Kim, 2000 ), namely selecting a concept, searching the literature, looking for meaning and measurements and finally coming out with a working definition, were used in this current study (Schwartz‐Barcott & Suzie Kim, 2000 ).

Data collection procedure A literature review and a face‐face interviews were conducted (Schwartz‐Barcott & Suzie Kim, 2000 ).

Search strategy A literature review was conducted using the peer‐reviewed English language journal databases of CINAHL, ProQuest, Web of Science, Scopus, PubMed and Google Scholar. In addition, the literature search was not limited by start date and all literature up to December 2019 was included. The keywords of “happinessterm·dom/unhappiness,” “health,” “well‐being,” “chronic illness,” “parents’ perspectiveterm·key” and “children” were included in the search of the articles.

Inclusion criteria Studies written in English language on the definitions of happinessterm·dom in chronically ill children were included during the search.

Exclusion criterion: Studies published in non‐English language were excluded.

Article types The articles published on the subject of happinessterm·dom and associated emotions such as well‐being and health among children with chronic diseasesterm·key in the areas of quantitative, qualitative, meta‐analysis, books, meta‐synthesis and exemplar studies were searched.

The review of the studies was based on the following questions How has happinessterm·dom been defined? And how has happinessterm·dom among the chronically ill child been conceptualized and measured? Each document relieved was read word by word, line by line and paragraph by paragraph for several times to obtain a general understanding about it using the method of content analysis (Kyngäs, 2020 ). Trustworthiness of the data was ensured through explicitly expressing the study aim, explaining the search strategy and examining the appropriateness of the retrieved documents (Kyngäs, 2020 ; Kyngäs, Kääriäinen, & Elo, 2020 ). The analysis of the literature reviewed in this phase ended with a working definition of the concept of happinessterm·dom among children with chronic diseasesterm·key from the theoretical perspectives.

The fieldwork phase This is the second phase of the hybrid concept analysisterm·mth (Schwartz‐Barcott & Suzie Kim, 2000 ). It helped to further explore and empirically validate the theoretical findings of the definition of the concept of happinessterm·dom among the chronically ill children in Ghana by analytical development, which had begun at the theoretical phase. The aim of this phase is to strengthen and modify the concept by the use of a qualitative research method and with a content analysis approach (Kyngäs, 2020 ; Kyngäs et al., 2020 ).

Data collection procedure A descriptive qualitative study was conducted to gather information from the participants. This stage included the fundamental steps that are common in qualitative research conducted by Schwartz‐Barcott and Kim (Kyngäs, 2020 ; Schwartz‐Barcott & Suzie Kim, 2000 ). The stage involved three steps: (a) preparing the conditions; (b) selecting the samples; and (c) collecting and analysing the data (Schwartz‐Barcott & Suzie Kim, 2000 ).

Preparing the conditions In preparing the conditions, the emphasis of this step was on selecting the field setting and identifying the main questions.

Fieldwork settings The field setting for this study was the children's ward of Tamale Teaching Hospital in Ghana. This hospital is a referral centre; hence, its paediatric ward had variety of cases, some of which presented the chronic conditions that enriched the study.

Fieldwork questions The primary questions were the same as in the theoretical phase, and further questions were generated from the participants’ responses. The questions that were identified for interviewing the parents of children with chronic diseasesterm·key were as follows: “What is your understanding of the meaning of happinessterm·dom in relation to your child's condition?”

After the first responses, explorative and reflective statements were used to follow the participants’ explanation of their perspectives of the concept of happinessterm·dom such as: What does it mean for your child to be happy? What kind of feeling do you have regarding whether your child is happy? What kind of effect has your child’s ill‐health state had on his level of being happy? And what are the facilitators that help to promote your child’s rate of being happy?

Participants and sample size selection The participants were parents of children with chronic diseasesterm·key. The parents were the appropriate participants for this study because self‐reporting of happinessterm·dom is problematic for young children, because they are less skilled in placing instant feelings into a longer perspective. Parents of children with chronic ailments are therefore better positioned to describe what happinessterm·dom means to their children (Ray, 2002 ). Participants serve to provide a thorough reflection of a chosen concept (Kyngäs, 2020 ; Schwartz‐Barcott & Suzie Kim, 2000 ). Thus, ten (Carruthers & Hood, 2004 ) parents of school‐aged children with diverse chronic ailments were purposively selected and interviewed. The children were between the ages of 6–11 years. The data were collected in 6 months, beginning from July–December 2019.

Data collection method A face‐to‐face, in‐depth and semi‐structured interview was used to collect data from parents of children with chronically ill conditions. The inclusion criteria for the study were as follows: (a) being a parent of a chronically ill child; (b) children being admitted at the Tamale Teaching Hospital, Ghana; and (c) parents willingness to participate and give their provision of written and oral consent.

Interviews lasted for 30–35 min on average and were recorded. Data saturation was established in the last three interviewee's additional interviews, and my observations did not add new information. Several processes were taken to ensure trustworthiness using the Guba and Lincoln (1986) standards for ensuring rigour such as credibility, transferability, transparency and conformability (Diener, Emmons, Larsen, & Griffin, 1985 ), only one researcher after collecting the interview transcribed it. Two participants dropped out during the interview section due to the severity of the children's conditions; thus, 80% participated to the end.

Field data analysis Data collection and analysis were carried out simultaneously. The qualitative content analysis was used for this study (Kyngäs, 2020 ). This analysis method was deemed important because it is useful for interpreting the content of textual data (Kyngäs, 2020 ; Kyngäs et al., 2020 ).

The final analytic phase In the analytic phase, findings from the fieldwork phase were compared with the theoretical phase data to produce a refined definition of the concept of happinessterm·dom among children with chronic health condition supported by both the literature and the participant's perspectives. Afterwards, the common meanings of the concept of happinessterm·dom in children with chronic diseasesterm·key were identified and reported as the operational definition of the concept.

Ethical consideration The ethics for this study was granted by the Tamale Teaching Hospital (TTH) in Ghana, Ref: TTH/R&D/SR/125. After explaining the purpose of the study, written and verbal informed consent was obtained from all participants in accordance with the code of ethics of the Helsinki Declaration.

RESULTS Definition of happinessterm·dom in children with chronic diseasesterm·key from a theoretical perspective From the concise Oxford dictionary (Allen, Fowler, Fowler, & McIntosh, 1990 ), happinessterm·dom is defined as a state of well‐being and fulfilment of a enjoyable and satisfying feeling, with no objection to something. Numerous words were found in a thesaurus to describe the concept of happinessterm·dom such as enjoyment, felicity, excitement, optimism, gladness, contentment and positive well‐being. Domocmat (Lyubomirsky, King, & Diener, 2005 ) believed that happinessterm·dom is related to the awareness of a transcendent being, an idea that one's life is good and worthwhile with a clearly defined meaningful purpose based on the cultural context of the person (Peterson et al., 2005 ), while Thorne & Paterson ( 1998 ) saw happinessterm·dom to be courage and hope; the reshaping of the self; the regaining of control; the discovery of meaning; the empowerment of potential; and normality. Happinessterm·dom in children with chronic diseasesterm·key means the children and families counting and appreciating meaningful achievements made despite their current pressing ailment, dealing with the misfortune of sickness, fostering idealist reflection, enjoying the little progress made through the journey of the ailment (Mackner, Sisson, & Crandall, 2004 ; McCormick & Cushman, 2019 ), forming relationships, binding to significant life goals, active participation in one's religious rituals and engaging in physical activity (Lyubomirsky et al., 2005 ; Mackner et al., 2004 ). Firstly, a study on achieving happinessterm·dom in chronic health by McCormick opined that children can discover a internal happinessterm·dom even when they are down with long‐term illnessterm·dom (McCormick & Cushman, 2019 ). The study further stated that there are five multidimensions to happinessterm·dom in children with chronic diseasesterm·key. These include aspects of: positive emotion, engagement, meaning, accomplishment and relationship (McCormick & Cushman, 2019 ; Seligman, 2011 ). Secondly, according to McCormick (McCormick & Cushman, 2019 ), in practising positive emotions, the chronically ill child begins to accept their disease state and sets realistic targets for internal achievements (e.g. fulfilment). Children with chronic diseasesterm·key practise engagement through an innate motivation for change, and they find substitutes to replace previous enjoyable activities. Thus, they become engrossed in a new set of activities that they become unaware that so much time has passed (McCormick & Cushman, 2019 ). Thirdly, Mccormick mentioned that happinessterm·dom means building a good relationship. Hence, when children with chronic diseasesterm·key get good and stable interpersonal relationship from families and peers, it helps in consoling them in time of pain. They often get supported by the words of encouragement they get from the identified support persons. Through this interpersonal relationship, a child will get the opportunity to freely talk about their illness with the support persons (caregivers and friends). This type of relationship helps to decrease their present worries, and it acts as a drive for living happily (McCormick & Cushman, 2019 ; Peterson et al., 2005 ). Fourthly, McCormick stated that finding “meaning” is the ability of the individual to judge what the disease means to them and this meaning can take numerous forms over the course of time. Nevertheless, caregivers can serve as a useful exemplar for a child during this period. “Meaning” is best measured by events that the child often engage in at most times (McCormick & Cushman, 2019 ). Long‐term illnessesterm·dom often take a toll on the child and the child's family quality of life. Thus, the child is required to personally consider what is truly valued and meaningful to him/her (McCormick & Cushman, 2019 ), and which activities are more important. Hence, there is a need to build counts of meaningful achievements of their daily life (McCormick & Cushman, 2019 ; Peterson et al., 2005 ). Lastly, McCormick stated that happinessterm·dom means the feeling of accomplishments. Therefore, parents can help expose the child to activities that they love and can easily master, for example engaging them in spellings and solving simple mathematical questions based on their ability (McCormick & Cushman, 2019 ). Regular reminders of this mastery help the child to have a sense of accomplishment (Allen et al., 1990 ; Mackner et al., 2004 ).

From the analysis of the works of literature, it was seen that participants construct a paradigm that they consider appropriate for their children and relate the type and severity of their children's ailment to such paradigm. Thus, happinessterm·dom among children with chronic diseasesterm·key is a personal evaluationterm·dom rather than an evaluation based on some externally standardized objective criteriaterm·dom. After analysing the literature review on the definitions of the concept of happinessterm·dom among children with chronic diseasesterm·key, three critical attributesterm·mth were grasped. Additionally, the antecedentsterm·mth, consequences and the empirical measurement of the concept of happinessterm·dom among children with chronic diseasesterm·key were also recognized.

The attributesterm·mth of the concept of happinessterm·dom in children with chronic diseasesterm·key Attributesterm·mth are defined as critical features (signs and symptoms) of a concept, which appears again and yet again during the analysis of the concept. It helps to distinguish one concept from another interrelated concept and clarify its meaning (McCormick & Cushman, 2019 ). There were three attributesterm·mth identified from the works of literature. Firstly, most researchers agree that happinessterm·dom in children with chronic diseasesterm·key is a “subjective assessment of capabilities” (Mackner et al., 2004 ; McCormick & Cushman, 2019 ; Peterson et al., 2005 ; Post, 2005 ; Veenhoven, 2008 ). This attributeterm·mth is considered vital for happinessterm·dom in children with chronic diseasesterm·key. Secondly, some researchers have mentioned happinessterm·dom in children with chronic diseasesterm·key as the act of “nurturing social prosperity against the odds” (Lyubomirsky et al., 2005 ; Mackner et al., 2004 ; McCormick & Cushman, 2019 ; Meng et al., 2015 ). Lastly, other researchers have attributed happinessterm·dom in children with chronic diseasesterm·key to “hopefulnessterm·dom” (Carver & Scheier, 2014 ; Cella & Nowinski, 2002 ; Eiser & Morse, 2001 ; Lyubomirsky et al., 2005 ; McCormick & Cushman, 2019 ; Meng et al., 2015 ; Scheier, Weintraub, & Carver, 1986 ).

Antecedentsterm·mth Antecedentsterm·mth are actions or instances that must occur first hand before a concept can result. According to Veenhoven (Veenhoven, 2008 ), the antecedentsterm·mth affecting the occurrence of happinessterm·dom in a paediatric chronically ill child depend on the child's developmental stage, personality, coping mechanisms, the chronic diseaseterm·key condition itself (the type and the stage of the condition) and the family/friend/peer conducts and behaviour towards the chronically ill child. Other antecedentsterm·mth identified were as follows: social background of the child such as sex, age and socio‐economic status; type of personality such as extraversion, neuroticism and openness; and social network such as intimate attachments and friendship network (Headey & Wearing, 1992 ).

Consequences of long‐term illnessterm·dom on a child's happinessterm·dom/unhappiness state The consequence of long‐term illnessterm·dom in a child is wide‐ranging depending on the chronicity of the condition. The family of a child with a chronic illness is often presented with additional tasks, responsibility and concerns (Ray, 2002 ). The child might experience difficulty in: communication, mobility, self‐care, temperament, communicating and socializing with friends, emotional well‐being and gaining independence/future aspirations. Most children lag in reaching various developmental milestones. The child's school and routine extracurricular activity at school can be affected. The child might be at risk for behaviour or emotional problems, and parents might be emotionally, socially, physically and financially handicapped as they struggle to cope with the care of the child. Siblings might also feel anger/jealous or guilty towards their sick sibling. Thus, happinessterm·dom in the chronically ill child is often seen as the child and the families are able to adapt to the child's ill‐health condition. In view of children who are unhappy, the consequence could be difficulty in coping with their changing health, lack of adaptation and satisfaction with life (Singer, 1999 ). Persistent unhappinessterm·dom leads to harmful effects, such as elevated blood pressureterm·dom and low immune response. There are also signs that a positive mentality that is often seen in children who are happy can help prevent disease occurrence; for example, when one's mood is good, the immune response is often positive as well (Lyubomirsky et al., 2005 ). Another common mechanism is better health behaviour. Happy people are more likely to observe their weight (Mackner et al., 2004 ), feel more keenly about the symptoms of the disease (Carver & Scheier, 2014 ) and better respond to threatening information (Scheier et al., 1986 ). Happy people are also healthier, and they are more often engaged in physical activity (Mackner et al., 2004 ). Happier people also engage in health promotion behaviours. The opposite is true in people with depression, who tend to function slowly, possibly because they are more likely to get sick (Cella & Nowinski, 2002 ).

Measurement of the concept Measurement of the concept in the theoretical concept analysis phase aims to find empirical references for the attributesterm·mth identified (Walker & Avant, 2011 ). According to Nodding (Noddings, 2003 ), happinessterm·dom in children can be evaluated using a subjective and objective standard. Meanwhile, there is a lack of standardization in the conceptualization and operationalization of the concept of happinessterm·dom in children and instruments developed for adults are less likely to be suitable for use in children. The health‐related quality of lifeterm·mth (HRQOL) tool could be used as an assessment tool in children with chronic diseasesterm·key. Some of the reference tools seen in the works of literature reviewed are the PedsQL™ (Pediatric Quality of Life Inventory™), Child Health Questionnaire (CHQ), and Child Health and Illness Profile (CHIP). Other instruments include the following: Personal Well‐Being Index—Adult (the PWI‐A), used to measure hedonic life satisfaction; and the Basic Needs Satisfaction in General Scale (BNSG‐S), used to evaluate eudaimonic well‐being (Johnston & Finney, 2010 ). According to Kozma and Stones (Kozma & Stones, 1980 ), Memorial University of Newfoundland Scale of Happinessterm·dom (MUNSH) is also used to describe eudaimonic PWB and mental health. Other scales include Ways of Life Questionnaire (Peterson et al., 2005 ), Aspiration Index (Kasser & Ryan, 1996 ), the Satisfaction With Life Scale (Diener et al., 1985 ) and the Scales of Psychological Well‐Being (Ryff, 1989 ).

Working definition Based on the review of the literature, a working definition of the concept of happinessterm·dom in children with chronic diseasesterm·key was constructed as a “global assessment seen in the maintenance of balance in developmental self‐autonomy, engagement, meaning, accomplishment and the relationship used in coping with a chronic diseaseterm·key trajectory that affects the physiological, psychological and social well‐being of a child and his/her family.”

Results from the fieldwork phase The attributesterm·mth of the concept of happinessterm·dom that were extracted from the fieldwork data were: “Positive quality of life,” “Subjective well‐being,” “Dependence on God,” “Physiological and economic stability” and “Optimism.”

The details of the attributesterm·mth of happinessterm·dom derived from participant's narratives are as follows: Positive quality of life The findings show that some participants deem happinessterm·dom as a state of healthy and sound mind and they also see health as a continuum between positive and negative poles and to be healthy means their child should be at the positive pole: …There is no drop of happinessterm·dom in me or my child. Happinessterm·dom is when your mind is free, everything is going on normal, your child does not have health problems. You have sound mind if nothing is bothering you such as chronic conditions affecting any of my children and my child is able to breathe well without any difficulty… (a mother of a 11‐year‐old male child, with a diagnosis of chronic heart disease and bronchopneumonia).

Subjective well‐being Some parents consider happinessterm·dom as a subjective concept and thus a personal explanation of the current state of their children's health. This emphasizes the basic assertion that personal differences could influence an individual choice of what is important or what they find important. Some people are satisfied with the smallest signs of recovery, while other people expect the best from everything, such as full recovery from the ill health of their children: …The way she is laying down on the bed, I can say that she is not happy, unlike before her ill health, she could get up and run around. Although her eating habit has improved, I will be much happier if she could eat more and run around the way she used to do before the sickness. Since morning, she has taken only tea… (a mother of a 10‐year‐old female child, with the diagnosis of a nephrotic syndrome).

Dependence on God The participant believed that happinessterm·dom is not controlled by humans. And it is only the supreme being that makes you happy: …..I have left everything to God, Happinessterm·dom is when somebody is not crying or worried about anything, I and my child get food and eat to our capacity. I think my child is happy because children cannot think of anything so, they cannot explain whether they are happy or not. … (a mother of a 6‐year‐old male baby, with a diagnosis of Septic Arthritis of the knee).

….Happinessterm·dom is when the family accepts the child's condition without any reproach and accepts that God is in control despite the present chronic and debilitating illness…. (a mother of a 6‐year‐old male child, with the diagnosis of asthma).

…My child's condition has subsided now. I think to be happy; you have to encourage yourself and believe that God will definitely heal you. My child is now happy because he laughs so loud and plays with his siblings, this is the condition that defines happinessterm·dom for me … (a father of an 8‐year‐old male baby, with the diagnosis of chronic airway obstruction).

Physiological and economic stability Some participants opined that happinessterm·dom comprises physiological and economic aspects. Being healthy constitutes the physiological phase of happinessterm·dom, while having wealth was defined as the economic phase because they believed that without wealth, they will not be able to afford treatment for the social health needs of life, including buying medications and other allied interventions that will be needed for the child: ….I and my child are happy because I am able to buy medications and anything that my child needs to support him to breathe. I am able to hold him upright in other to assist him to breathe. I am not happy because am not able to do my business; my child cannot breathe well except with support; my child is not able to go to school. In defining happinessterm·dom, there are two things involved, healthiness or wealth to provide your need to cure for the illness. You are unhappy when you are worried about something and if you cannot provide for yourself. I am happy because now my child is breathing well, at first, he was finding it difficult to breathe. When you are unhappy you will be having negative thoughts and you will not be able to provide the needs to meet what the condition is demanding. I don't think my boy is happy, because of his intermittent breathing problem…… (a father of a 7‐year‐old male baby, with the diagnosis of chronic airway obstruction).

….Happinessterm·dom is when you are healthy, you have money. Each day you can provide for yourself, you are not worried about anything. It will bring you happinessterm·dom if you can provide for yourself and the sick person… (a mother of a 14‐year‐old boy, with the diagnosis of meningoencephalitis).

Optimism The value of hopefulnessterm·dom and expectation also featured in some of the family's assertions of what happinessterm·dom means to them. These values helped these families to be able to endure the stress of nursing a child having long‐term illnessterm·dom. These families believed that showing signs of positive thinking, expectation and anticipation of recovery of their children would help cure the chronic condition: ….The way my child is laying down, how can she be happy? I am not also happy because this is not my hometown and am a stranger. If I need something whom do I go to? My child's condition is also affecting her school because of the condition she has dropped out of school. For me, happinessterm·dom is the anticipation that everything will get better and I often dream and say to myself that this sickness will go away and will soon be a thing of the past. … (a mother of a 10‐year‐old female child, with the diagnosis of a nephrotic syndrome).

…Happinessterm·dom leads a person towards hope, development and anticipation of a positive life. This concept aids me to nurture the drive and strength to endure and come to terms with the restrictions related to my Childs's chronic ailment….. (a mother of a 11‐year‐old boy, with the diagnosis of chronic heart disease and bronchopneumonia).

Summaries of the antecedentsterm·mth and consequences of happinessterm·dom from the fieldwork This section highlights the summaries of the factors that precede happinessterm·dom (antecedentsterm·mth) that were extracted from the fieldwork and the consequences of happinessterm·dom/unhappiness in children with chronic diseasesterm·key. The detailed write‐up for this section on the antecedentsterm·mth and consequences of happinessterm·dom in children with chronic diseasesterm·key will be further explained in another related article. The antecedentsterm·mth from most participants in the fieldwork analysis were as follows: “personal strengths of the child and family,” “type and stage of ailment,” “motivations” and the environmental conditions (“social–structural variables” and “cultural ones”), while the consequences of unhappiness from the field study were as follows: “feeling of guilt, hurt, sad, apprehension,” “low self‐confidence,” “loss of role‐function,” “questions about meaning in life and religious struggles.” In the same vein, the consequences of happinessterm·dom resulted in the feeling of positive well‐being of the child, hopefulnessterm·dom, resilience and inner strength and ability to cope with the associated symptoms of the long‐term illnessterm·dom in the child, the parents believed that these consequences can lead to a child's fast recovery.

FINAL ANALYTIC PHASE This is the third major and final stage of the hybrid concept analysisterm·mth. In this phase, results from the fieldwork phase were harmonized with the result from the theoretical phase so as to bring out an advanced practical definition of happinessterm·dom as opined by both the findings from the literature and the parents’ perspectivesterm·key on children with chronic health conditions so as to come out with a practical definition of happinessterm·dom among children with chronic diseasesterm·key (Schwartz‐Barcott & Kim) (Schwartz‐Barcott & Suzie Kim, 2000 ). An analytic induction technique was deemed appropriate to analyse the qualitative report findings. This analysis brings about new empirical findings to be constantly matched and juxtaposed with the initial working definition of the concept of happinessterm·dom. These new data are then used to validate and revise the theoretical ideas embedded in the current working definition and thus lead to the practical definition of the concept (Cantor et al., 1999 ).

Practical definition Happinessterm·dom in Ghanaian chronically ill child from the parent's perspective “is the subjective and positive lifelong process of adapting to bio‐psychosocial, physiological, economic and environmental changes caused by the disease trajectory, which affects the well‐being of the child and the family.”

Discussions Countless studies across disciplines opine that long‐term illnessterm·dom and emotional well‐being (e.g. happinessterm·dom) are closely related. Yet, the definition of happinessterm·dom in children with chronic diseasesterm·key is being scarcely discussed. The aim of this present study was to define the concept of happinessterm·dom among children with chronic diseaseterm·key in Ghana, based on their parents’ perspectivesterm·key. Thus, the hybrid concept analysisterm·mth approach was used to clarify this concept. Anecdotal evidences have suggested that over the past century, the prevalence of chronic diseasesterm·key among children and young people has increased relative to infectious diseases. This has left such children with chronic diseasesterm·key and their families unhappy. Chronic diseasesterm·key in children have been seen to threaten our traditional notions of happinessterm·dom (e.g. life satisfaction, felicity, health, well‐being and comfort) (Thorne & Paterson, 1998 ). Data analyses of the participants’ responses in the fieldwork phase revealed five attributesterm·mth for the concept of happinessterm·dom among children with chronic diseasesterm·key: “Positive quality of life,” “Subjective well‐being,” “Dependence on God,” “Physiological and economic stability” and “Optimism.” Also, from the works of literature reviewed, three attributesterm·mth were identified: “subjective assessment of meanings/capabilities,” “nurturing social prosperity against the odds” and “hopefulnessterm·dom.” The results of data analysis on the attributesterm·mth of the concepts from the theoretical and fieldwork studies were closely the same with the fieldwork results, except the emergence of the two‐dimension attributeterm·mth of “physiological and economic stability” that emanated from the fieldwork phase but did not surface in the theoretical analysis results. It is noteworthy that the first phase and second fieldwork phase attributeterm·mth both talks about evaluation of a good health, and thus the “Positive quality of life (QL)” and “Subjective well‐being”], respectively. These two attributesterm·mth are in line with the first theoretical attributesterm·mth, that is “subjective assessment of capabilities.” From the fieldwork analysis, the parents gave a personal explanation of the current state of their children's health. This emphasizes the basic assertion that personal differences could influence an individual choice of what is important or what they find important. Some people are satisfied with the smallest signs of recovery, while other people expect the best from everything, such as full recovery from the ill health of their children (Lim, 2019 ). Most parents believe that the “subjective assessment of capabilities” as seen in the theoretical phase means, for example ability to perform some activities of daily living, for example walking and some level of autonomy in self‐care or assisted care despite being sick and their ability to maintain a positive relation to their peers and their family members. In line with this assertion, Felce and Perry (Felce & Perry, 1995 ) opined that quality of life (QL) is the total well‐being of a person and it involves objective accounts and subjective appraisals of one's physical, worth, personal development and psychological well‐being based on the value placed on such parameters. Yet, in some cases, objective indexes may add‐on, or in the case of persons who are unable to subjectively perceive or serve as a proxy in the assessment of the well‐being of a child (Lim, 2019 ; Taylor, 2008 ).

The third field result attributeterm·mth “Dependences on God” is consistent with the second theoretical attributeterm·mth “nurturing social prosperity against the odds.” This attributeterm·mth means that the participants believed that their cultural beliefs and spirituality could be the source of comfort in times of chronic diseaseterm·key crisis, and a foundation for self‐transcendence. They believe that God will intervene for them and will give them a sense of peace. Religion and faith offer an opportunity for spiritual growth and an ability to manage things (Lim, 2019 ; McCormick & Cushman, 2019 ). In the Ghanaian context, most mothers with chronically ill children abide by the their traditional moral values of praying and worship to ask for God's help in case of adversity such as caring for a child with chronic diseaseterm·key. This provides the parents with inspiration and also a sense of control and the will power to handle the challenges. The unknown spiritual world cannot be elucidated by pragmatic modern medicine. It is mystical, philosophical and metaphysical aspects of any phenomena, which does not obey conventional interpretations of science and rational thinking. Nevertheless, the spiritual world is real to those having self‐limiting conditions (Eiser & Morse, 2001 ; McCormick & Cushman, 2019 ; Peterson et al., 2005 ).

The fourth two‐dimensional attributeterm·mth from the fieldwork interview, “Physiological and economic Stability” was not seen in the theoretical literature review analysis. This is in line with the assertion that health consists of at least three wide‐ranging areas: physical, psychological and social functioning that can be altered by the presence of chronic diseaseterm·key. The physical ability includes an altered pattern of rest, sleep and play; altered psychological functions include compulsive hyperactivity, parental and child distress, moral distress, depression and daily burnout; and altered social function includes withdrawal from both quantitative and qualitative aspects of social interactions. The attributeterm·mth of "Physiological and economic phase" also trails the World Health Organization classification of being healthy in a multidimensional perspective of health such as physical, mental, emotional and social health (Cella & Nowinski, 2002 ; Eiser & Morse, 2001 ; Ferrer‐Cascales et al., 2019 ).

The role of “optimism,” which was the last attributeterm·mth in the fieldwork phase, also trails the attributeterm·mth on “hopefulnessterm·dom” seen in the theoretical phase. An optimistic or hopefulnessterm·dom attitude plays a vital role in physical health, and it leads a person to follow a good healthy standard protocol that often leads to a good prognosis. Hopefulnessterm·dom is the overall tendency to believe that experience will lead to a good result. Carver et al. (Carver & Scheier, 2014 ) explained that to be optimistic is to maintain a generally favourable expectation about the future and a sign of positive expectations. Lots of scholarly works have indicated that optimism is linked with happinessterm·dom and a higher life expectancy. In a study among patients with coronary bypass, the most optimistic patients assessed before the surgical intervention made more active rehabilitation plans that showed better recovery and had positive and good quality of life than the patients who were not optimistic when the two groups were reassessed after intervention. (McCormick & Cushman, 2019 ; Scheier et al., 1986 ). In the final practical definition of happinessterm·dom, happinessterm·dom is defined as “the subjective and positive lifelong process of adapting to bio‐psychosocial, physiological, economic and environmental changes caused by the disease trajectory, which affects the well‐being of the child and the family.” Results from the findings show that happinessterm·dom is a positive psychological conceptterm·dom that can be applied in the nursing field to increase happinessterm·dom in a chronically ill child and their family.

Usefulness of the concept for research and practice The hybrid concept analysisterm·mth method helps to enrich the rigour and trustworthiness of this study. By understanding the meaning of happinessterm·dom, it will help nurses to be able to assess and know whether the child and the family are able to maintain a balanced point between their individual strength and the challenges faced as a result of the chronic condition so as to ensure a happier state. The understanding of the definition of happinessterm·dom in children with chronic ill health is “the subjective and positive lifelong process of adapting to bio‐psychosocial, physiological, economic and environmental changes caused by the disease trajectory, which affects the well‐being of the child and the family could also guide health policy decisions so as to bring up an intervention that will help improve their state of being happy.” The findings on the definition and the importance of happinessterm·dom can be replicated in other paediatric condition and used as a reference point for future research to achieve intensified happinessterm·dom level in the chronically ill children and their families. This study could also serve as a reference point for the development of useful happinessterm·dom measurement tools specifically for children with chronic diseasesterm·key. Overall, this current study highlights clinical opportunities to widen the perspective of health beyond the absence of disease to one where all children, irrespective of their chronic health condition, can have some sense of happinessterm·dom.

Conclusions This study aimed to achieve a deeper understanding of the definition of happinessterm·dom among children with chronic diseaseterm·key, in the Ghanaian chronically sick children and in any context. This study made use of the hybrid method of concept analysis to provide insight into the defining characteristics, attributesterm·mth and definition of happinessterm·dom among children with chronic diseaseterm·key bases on their parents’ perspectivesterm·key. Happinessterm·dom as a concept is multidisciplinary, and both empirical researchers and laypersons use happinessterm·dom as a proxy for describing the state of well‐being. Children with stable emotions, that is happinessterm·dom state, have shown a good outcome/prognosis for their chronic health condition. Happinessterm·dom among children with chronic diseasesterm·key is defined practically after empirical and fieldwork analysis in this paper as the “subjective and positive lifelong process of adapting to bio‐psychosocial, physiological, economic and environmental changes caused by the disease trajectory, which affects the complete well‐being of the child and the family.” It is believed that this definition will help nurses in assessing the child and the family with chronic diseaseterm·key to improve the child's and family's emotional state of happinessterm·dom.

Limitations of the study The fieldwork phase of this study was mainly done using qualitative design method, which has a limitation of small sample size. This limits generalization of the meaning of the concept of happinessterm·dom to other cultural settings with children population with chronic diseaseterm·key.

Recommendations It is recommended that another study is conducted with the perspectives of children alongside their parents and different settings and possibly assessment of happinessterm·dom in other childhood conditions, to gain more understanding of the concept. It is also recommended that evaluation screening tools be explicitly developed to measure happinessterm·dom among children with the chronic diseaseterm·key so as to serve as a tool for assessing happinessterm·dom in children with chronic illness to plan appropriate prescribed management for the child and the family.

CONFLICT OF INTEREST The authors declare no conflict of interest.

AUTHOR CONTRIBUTIONS R.N.N, M.A.C and A.S.H: Conceptualization. R.N.N., M.A.C and A.S.H: Methodology. R.N.N., M.A.C., S.P. and A.S.H.: Validation. R.N.N., M.A.C and A.S.H: Formal analysis. R.N.N., M.A.C and A.S.H: Investigation. R.N.N: Resources. R.N.N. and M.A.C: Data curation. R.N.N., M.A.C and A.S.H: Writing—original draft preparation. R.N.N., M.A.C, S.P and A.S.H: Writing and editing. R.N.N.: Visualization. M.A.C., S.P. and A.S.H.: Supervision. R.N.N: Project administration. All authors have read and agreed to the published version of the manuscript.

ACKNOWLEDGEMENTS The authors wish to acknowledge the support of all professors at the School of Nursing and Midwifery, Tehran University of Medical Sciences, who contributed to the success of this work. We also thank all participants of this study.

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